The Key to Treating Stroke: Knowing When to Stop

With endovascular therapy as the standard of care in ischemic stroke and with a community of interventional cardiologists increasingly committed to assisting neurologists in providing 24/7 thrombectomy, staying informed is paramount.

La clave para tratar strokes: saber cuando detenerse

The number of thrombectomy attempts with retractable stent (>3) is associated with hemorrhagic transformation beyond age, baseline NIHSS (National Institutes of Health Stroke Scale) score, or procedure time. This information is important to decide whether to continue with the procedure or not.

The German Stroke Registry included 2611 patients who underwent endovascular therapy for acute cerebral infarction due to large-vessel occlusion of the anterior circulation. All had known baseline NIHSS, early tomography, known final TICI (the homologue of TIMI flow for the brain), and known number of attempts made.

The primary endpoint was symptomatic hemorrhagic transformation rate.

A mean of 2 tries (range: 1-3) was observed in the general population with a symptomatic hemorrhagic transformation rate of 4.4%, and 143% detected only through neuroimaging studies.

After adjusting for multiple variables, >3 attempts multiplied the hemorrhagic transformation risk almost four-fold (odds ratio [OR]: 3.61; 95% confidence interval [CI]: 0.27 to 9.42; p = 0.0089). An Alberta tomography score of 8-9 (or, better yet, 10) at admission was a protective factor against hemorrhagic transformation.


Read also: Watch again our Webinar on TAVR in Low-Risk Patients.


For interventional cardiologists, the temptation to think that all artery disease is the same can be significant when facing a stroke.

Skill in catheter management should not obscure the major differences in the risk of insisting, timing, and the clinical benefit of artery re-patency.

Conclusion

Performing more than 3 thrombectomy attempts significantly increases the risk of hemorrhagic transformation regardless of patient age, baseline NIHSS score, or procedure time. This should be considered when deciding whether to continue with the procedure, especially in patients with large stroke.

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Original Title: Number of Retrieval Attempts Rather Than Procedure Time Is Associated With Risk of Symptomatic Intracranial Hemorrhage.

Reference: Máté Elöd Maros et al. Stroke. 2021;52:00–00. DOI: 10.1161/STROKEAHA.120.031242.


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